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Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).
History of the present illness (HPI) – details about the complaints, enumerated in the CC (also often called history of presenting complaint or HPC). Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as past surgical history or PSH), any current ongoing illness, e.g. diabetes).
The physician will take a history of present illness, or HPI, of the CC. [1] This describes the patient's current condition in narrative form, from the time of initial sign/symptom to the present. [10] It begins with the patient's age, sex, and reason for visit, and then the history and state of experienced symptoms are recorded. [1]
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An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Hospitalization for any illness in the past; Urinary changes (especially if diabetic or elderly) Gastrointestinal complaints (diet changes, bowel movements, etc.) Sleep pattern (waking up/going to sleep, etc.) Family history (similar chief complaints/serious illness) OB/GYN history (LMP, abortions, etc.) Sexual habits (active/preferences/STD, etc.)
The term chief complaint, also "presenting problem", is used to describe the initial concern of an individual when seeking medical help, and once this is clearly noted a history of the present illness may be taken. The symptom that ultimately leads to a diagnosis is called a cardinal symptom.
The parts of the mnemonic are: Onset of the event What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain, [2] and whether the onset was sudden, gradual or part of an ongoing chronic problem.